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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS rJ 14 J Cr CIC CITY/ZIP - ei'`i i �f g CROSS STREET APN 2301b PARCEL SIZE S - Y 0 OWNER NAME )nar maroro PHONE OWNERADDRESS 3 71 t IJP°"YJL191Lt� �)"iie —CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I C-42 I I C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y Cl PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED./A TERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION lu INSTALLATION WILL SERVE: L RESIDENCE U COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY L ft ❑ SUMPS WIDTH It LENGTH _ ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE Ep ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ��!- ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPW LINE ` 1 ZU1 ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH Pokn96QUIN r ni.— ft DISTANCE TO NEAREST WELL FOUNDATION ft PRO vrV►� ft MEIyT,gL ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 42 MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNEDI''`" TITLE L' DATE .L1 GJGU ly �' C Gf S rz _ DEPARTMENT USE ONLY I ,, Application Accepted By Date - 2 I- )k Area _/��Z Employee ID# w U J� Final Inspection By Date [201 Id ❑ SPECIAL PERMIT-Approved by Character of Soil to De?of 3 Ft: _ Pit/Sump Soil Character: COM ENTS 1 Pe / YYI G h . o hcloc . A114 ' e,fvtovG (2 3 I, Vcr �� -f-u.�'`�n� ate `>°�% A 2 3 l� {/ IAV k� aVl zC t srl^� J 2 Yt �J� L l: DIM{ t 7-1 �2f4f�Y�C f� �k �{nC °I,cWI PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B C sh Remitted Service Request# q;Ll ) 07S S R00 7 -7 42-01D ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17